What is the appropriate management for an adult patient with a history of neck pain or stiffness and CT cervical spine findings at the C5-C6 level showing disc osteophytic change and bilateral unconventional osteophytes, indicative of a degenerative condition such as spondylosis?

Management of C5-C6 Disc Osteophytic Changes with Bilateral Uncovertebral Osteophytes

For an adult patient with CT cervical spine showing disc osteophytic changes and bilateral uncovertebral osteophytes at C5-C6, the next step depends entirely on the presence or absence of neurological symptoms: if the patient has radiculopathy (arm pain, numbness, weakness) or myelopathy (balance problems, leg weakness, gait disturbance), obtain MRI cervical spine without contrast immediately; if the patient has only neck pain without neurological symptoms, initiate conservative management without additional imaging. 1

Clinical Assessment Framework

The CT findings you describe represent degenerative cervical spondylosis, which is extremely common and often asymptomatic. 1 The critical decision point is determining whether these anatomic findings correlate with clinical symptoms:

Red Flag Assessment (Requires Immediate MRI)

Obtain MRI cervical spine without contrast if any of the following are present: 1, 2

• Radicular symptoms: Arm pain, numbness, or weakness following a dermatomal distribution 3
• Myelopathic symptoms: Weakness in both arms and legs, balance difficulty, gait disturbance, bowel/bladder dysfunction 2, 4
• Progressive neurological deficits: Worsening weakness or sensory loss over days to weeks 3, 5
• Severe or intractable pain: Pain unresponsive to 6 weeks of conservative management 3

Why MRI? CT excellently depicts the bony osteophytes you've already identified, but MRI is essential to evaluate what CT cannot show: spinal cord compression, nerve root impingement, disc herniation, ligamentous injury, and cord signal changes (myelomalacia). 1 The presence of bilateral uncovertebral osteophytes at C5-C6 creates a high risk for foraminal stenosis and nerve root compression that requires soft tissue evaluation. 1

Conservative Management (No Additional Imaging Needed)

If the patient has only neck pain or stiffness without neurological symptoms, no further imaging is indicated: 1

• Initial treatment: NSAIDs and physical therapy focusing on postural correction and cervical stabilization exercises 6
• Duration: Continue conservative management for at least 6 weeks before considering advanced interventions 7
• Follow-up: Reassess in 4-6 weeks; obtain MRI only if symptoms worsen or neurological deficits develop 6, 7

Critical Clinical Pitfalls

Overinterpretation of Imaging Findings

Degenerative changes on imaging correlate poorly with symptoms. 1 Approximately 65% of asymptomatic patients aged 50-59 years show radiographic cervical degeneration, and spondylotic changes are common in patients over 30 years of age. 1, 6 The presence of osteophytes does not automatically indicate they are causing symptoms. 1, 7

Do not order MRI for chronic, stable neck pain without neurological findings. 1 This leads to detection of incidental degenerative findings that do not correlate with symptoms and may drive unnecessary interventions. 2, 7

Underimaging Patients with Neurological Symptoms

Delaying MRI in patients with neurological deficits can lead to irreversible neurological damage. 2 Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction in older persons, and symptoms often develop insidiously. 4 The combination of bilateral uncovertebral osteophytes at C5-C6 creates anatomic risk for both foraminal stenosis (radiculopathy) and central canal stenosis (myelopathy). 1, 4

Specific Symptoms Requiring Urgent Evaluation

• Dysphagia or dysphonia: Large anterior cervical osteophytes can cause swallowing or voice problems, particularly at C4-5 and C5-6 levels 8, 9
• Occipital headaches or positional symptoms: May indicate atlantoaxial involvement or upper cervical pathology 6
• Sudden neurological deterioration: Requires emergency MRI and neurosurgical consultation 2, 4

Surgical Considerations

Surgery is indicated for: 3, 5

• Intractable or persistent pain despite 6 weeks of adequate conservative management 3
• Severe or progressive neurological deficits (weakness, sensory loss, myelopathy) 3, 5
• MRI-confirmed cord compression or significant foraminal stenosis correlating with clinical symptoms 4, 5

Refer to spine surgery if MRI demonstrates cord compression, significant canal stenosis, or progressive neurological symptoms. 6, 3

Imaging Modality Clarification

CT has already been performed and shows the bony pathology. 1 CT offers superior depiction of cortical bone and is more sensitive than radiographs for assessing osteophyte formation and uncovertebral joint disease. 1 However, CT is less sensitive than MRI for evaluating nerve root compression, particularly from herniated discs. 1

Do not order CT myelography unless MRI is contraindicated (pacemaker, severe claustrophobia) and neurological symptoms are present. 1

Do not add IV contrast to CT or MRI in the absence of red flag symptoms suggesting infection or malignancy. 1